Department of nephrology R1 이동영 Case Conference Department of nephrology R1 이동영

HISTORY 11734875 배O례 F/48 Admission : 06.01.19 Chief Complaint : Fever (onset:1day ago) Present Illness :10년 전부터 DM, HTN으로 medication하는 자로 2004년 8월 fever에 대해 ADPKD cystic infection 진단 받았고 당시 tube drainage 및 항생제 투여 받았음. 내원 1일 전 Lt. flank pain, fever 발생해 응급실 통해 비뇨기과로 입원함.

HISTORY Past medical Hx Family Hx Personal Hx alcohol (-) smoking(-) DM/HTN/TBc/Hepatitis(+/+/-/-) DM-humulin:26/10 IU HTN : anydipine 5mg qd OP Hx. (-) Family Hx Personal Hx alcohol (-) smoking(-) ADPKD ESRD, KTP후 expire

REVIEW of SYSTEMS General : fatigue(+) fever(+) chill(+) Malaise(+) H & N : headache(-) sore throat(-) Chest : dyspnea(-) chest pain(-) palpitation(-) cough(-) sputum(-) GI : A/N/V/D/C(-/-/-/-/-) abdominal pain(-) melena(-) hematochezia (-) Renal : dysuria (+) frequency (+) hematuria (-) voiding difficulty(+) Musculoskeletal : edema(-) swelling(-) Nervous : seizure(-) stroke(-)

Physical Examination V/S 110/70mmHg-100회/min-20회/min-38.0°C General : alert consciousness SKIN : no rash, no pigmentation H/N : no thyroid gland enlargement no cervical LN enlargement no neck vein engorgement E/ENT : isocoric pupil with PLR(++/++) pinkish conjunctiva , whitish sclerae Chest : clear breath sound without crackle regular heart beat without murmur Abdomen : soft and flat abdomen , abdominal Td/RT(-/-) abdominal palpable mass(-) , normoactive B.S. B/Ext : CVA tenderness(-/+) pitting edema(-/-)

Impression APN, r/o infected cyst Known ADPKD Known DM Known HTN

Plan CBC/DC, PT/PTT, Chemistry , CRP U/A , FENA,FEUN, ABGA Blood & urine culture Abd.sono

Lab Finding FENA=15.32,FEUN=100 CBC/DC :9530/mm3 - 10.7g/dL - 33.0 % - 175K/ mm3 (seg 84.8%) INR 1.00 aPTT 35C33 Chemistry: TB/DB 0.64/0.03 mg/dL AST/ALT 22/16 U/L ALP/rGT 44/16 mg/dL Prot/alb 6.9/3.5 g/dL BUN/Cr 25/1.9 mg/dL Ca/P 6.6/2.5mg/dL Na/K/Cl 138/4.2/105 mmol/L U/A : RBC 5-9/HPF, WBC Many/HPF, Protein(-) PH 5.0 Specific gravity 1.025, Occult blood (3+) Chest PA : No active lung lesion EKG : NSR FENA=15.32,FEUN=100

Previous admission Clinical course(2004-8-30) 2004-8-31 한 달 전부터 시작된 fever, Rt flank pain으로 서울성심병원에서 ADPKD 진단받고 항생제 치료 받았으나 호전 없어 본원 내원 Ampicilline + Tobramycin  Ciprofloxacin + Tobramycin 본원에서 bactrim으로 교체 후 Nausea, Vomiting 심해 약 D/C후 Ciprofloxacin투여 이후 열 지속되고 CT에서 infected cyst 의심되어 URO전과 후 drainage tube insert 및 항생제 치료 받고 퇴원

Previous admission Abd CT

Previous admission tube drainage and sclerotherapy 2004-8-31 2004-9-9

Abdominal sono(1.20)

Clinical course Cefotiam 투여 Ciprofloxacin투여

Clinical course

Clinical course 내원시 APN, Lt R/O cyst infection  항생제 투여시작(Cefotiam 1g bid iv) (05.01.19~)  항생제 투여 해도 임상증상, Lab 호전 없고 Cr ↑하는 acute on CRF 보여서 내과로 전원. Blood & urine culture에서 E.coli 관찰되었고 지속되는 증상에 대해 cyst infection 의심되어 항생제 변경(05.01.23~) : Cefotiam  Ciprofloxacin 200mg bid iv 이후 임상증상 및 Lab 호전, urine and blood Cx: no growth. Peak BT normalization 10일간 관찰 후 discharge

Final diagnosis APN Lt with cystic infection Known ADPKD Acute on CRF d/t infection and dehydration Type 2 DM Known HTN